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General NPI Number Information
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NPI Number | 1326622143
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Entity Type | Organization
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Legal Business Name | BEVERLY MEDICAL GROUP
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Dates
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Enumeration Date | 05/07/2021
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Last Update Date | 06/23/2021
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Provider Practice Location Address
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Address Line | 2105 BEVERLY BLVD STE 233B
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City | LOS ANGELES
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State | CA
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Zip | 90057-2216
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Country | US
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Telephone | 213-674-7859
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Fax | 213-277-1055
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Provider Business Mailing Address
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Address Line | 2105 BEVERLY BLVD STE 233B
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City | LOS ANGELES
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State | CA
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Zip | 90057-2216
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Country | US
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Telephone | 213-674-7859
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Fax | 213-674-7863
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Authorized Official
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Title or Position | CEO
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Name | NICHOLAS N DZEBOLO
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Credential | M.D
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Telephone | 132-771-0302
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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